Articles and Editorials

 

The alarming escalation in the incidence of obesity and diabetes presents significant challenges for healthcare practitioners, health systems, payer groups, and the government, not to mention the impact on the health of the individual. The epidemic increases in both of these chronic conditions necessitate the replacement of reactive management strategies that employ diet and exercise dictums, minimalist pharmacologic support, and delayed implementation with more proactive and assertive efforts that focus on the achievement of glycemic targets, cardiovascular risk reduction, and weight management.


The Medical Management of Hyperglycemia in Type 2 Diabetes: A Consensus Algorithm for the Initiation and Adjustment of Therapy, developed in early 2009 by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD), delineates the attributes of the various therapeutic classes and agents, and provides guidance for employing a stepped approach to achieve and maintain target glycemic control.1 It supports individualized risk assessment combined with the consideration of multiple pharmacologic therapies to determine treatment that addresses individual disease status, glycemic status, cardiovascular risk profile, and comorbid conditions.

It is well established that maintenance of near-normal glycemia reduces the risk of microvascular complications associated with type 1 and type 2 diabetes.2,3 Early evidence of the beneficial effects of glycemic control on cardiovascular risk in type 1 and type 2 diabetes have also been noted.4-6 However, cardiovascular disease continues to be the leading cause of morbidity and mortality for individuals with type 2 diabetes. A comprehensive approach to the management of diabetes, which combines lifestyle modifications with pharmacologic therapies to reduce risk of complications, is essential. Given that the presence of diabetes represents in itself an increased cardiovascular risk, more stringent treatment targets for these individuals are required.1

The relationship of obesity to the development and progression of diabetes brings new urgency to the importance of weight reduction and weight management. Reflecting on the dramatic increases in the incidence of obesity and the associated increases in the incidence of type 2 diabetes not only among adults, but also in children and adolescents, necessitates a paradigm shift in the medical approach to obesity. Healthcare practices must become more assertive, replacing bland, generic directives to patients such as “eat less” and “exercise more” with more progressive interventions that combine lifestyle modifications, risk evaluation, risk reduction, and disease prevention, while attending to disease management. The morbidity associated with obesity, and the close association of obesity with diabetes and cardiovascular disease, necessitates the development and implementation of integrated treatment strategies.

The American Diabetes Association’s 69th Scientific Sessions provided multiple reminders of the challenges facing healthcare practitioners treating diabetes, cardiovascular disease and obesity in 2009 and beyond. The depth and breadth of information presented is tangible evidence of the progress made in our scientific and clinical understanding over recent decades. However, while glycemic control remains the primary target of treatment for type 1 and type 2 diabetes, results from major multicenter randomized controlled trials such as UKPDS, DPP, ACCORD, ADVANCE, Look AHEAD, VADT, and others demonstrate the adverse impact of weight and other cardiovascular risk factors on health outcomes for patients with or at risk of developing type 2 diabetes.6-8 These data underscore the importance of an integrated approach to treatment of type 2 diabetes that addresses glycemic control, cardiovascular risk reduction, and weight management.

As healthcare practitioners, we are obligated to provide individualized and integrated medical care, assess therapeutic effectiveness, and provide ongoing guidance to best serve the patient. We are challenged to stay current with the escalating volume of new therapies, devices, and lifestyle recommendations and to understand the nuances of treatment strategies while balancing the realities of the world within which we practice. In the absence of updated information, which is subsequently applied to treatment approaches, health outcomes for patients with diabetes, obesity, and cardiovascular disease will not improve.

About iDOC

iDOC is a 24/7, online resource focused on diabetes, obesity, and cardiovascular disease, the interrelationships that exist between these conditions, and the importance of integrating treatment of these three conditions to improve health outcomes. iDOC’s mission is to positively impact outcomes for patients by enhancing healthcare provider knowledge and behavior through education. iDOC provides convenient, real-time access to education forums offering information about major clinical studies, current and emerging therapies, comprehensive treatment strategies, tips for mitigating treatment side effects, lifestyle strategies, monitoring suggestions, and more, to expand your clinical knowledge and expertise of these chronic conditions that impact the lives of so many. In addition, opportunities for interacting with experts skilled in the integrated management of diabetes, obesity and cardiovascular disease will provide real-world relevance and clinical applicability to inform and expand your treatment decisions.

Thank you for visiting iDOC. We hope you will register today and visit the site frequently as new content and features are planned to roll out.

Regards,
Steven R. Smith, MD
Scientific Director
Translational Research Institute for Metabolism
Florida Hospital
Professor
Diabetes and Obesity Research Center
Sanford | Burnham Medical Research Center
Orlando, Florida
  
References
  1. Nathan DM, Buse JB, Davidson MB, et al. Medical management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy: a consensus statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care. 2009;32(1):193-203.
  2. The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med. 1993;329(14):977-986.
  3. UK Prospective Diabetes Study (UKPDS) Group. Intensive blood glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet. 1998;352(9131):837-853.
  4. Nathan DM, Cleary PA, Backlund JY, et al; Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) Study Research Group. Intensive diabetes treatment and cardiovascular disease in patients with type 1 diabetes. N Engl J Med. 2005;353(25):2643-2653.
  5. Cefalu WT, Watson K. Intensive glycemic control and cardiovascular disease observations from the ACCORD study: now what can a clinician possibly think? Diabetes. 2008;57(5):1163-1165.
  6. Holman RR, Paul SK, Bethal MA, et al. 10-year follow-up of intensive glucose control in type 2 diabetes. N Engl J Med. 2008;359(15):1577-1589.
  7. Skyler JS, Bergenstal R, Bonow RO, et al. Intensive glycemic control and the prevention of cardiovascular events: implications of the ACCORD, ADVANCE, and VA diabetes trials: a position statement of the American Diabetes Association and a scientific statement of the American College of Cardiology Foundation and the American Heart Association. Diabetes Care. 2009;32(1):187-192.
  8. Reaven PD, Emanuele N, Moritz T, et al. Proliferative diabetic retinopathy in type 2 diabetes is related to coronary artery calcium in the Veterans Affairs Diabetes Trial (VADT). Diabetes Care. 2008;31(5):952-957.